Here’s a little “Acne 101” for the students in your life heading back to school, and for those like me who have acne-prone skin... what causes those blemishes and how to prevent and treat them!
Sebum (a waxy oily substance produced by glands in our skin), mixed with dead skin cells, blocks the openings to the pores, creating whiteheads or, if oxidized, blackheads. When oil and bacteria (specifically propionibacterium acnes [P. acnes]) become trapped in pores, the bacteria breaks the oil down into fatty acids that create irritation and inflammation along with the P.acnes infection. It is known that androgen (male hormone) stimulation causes changes in the pilosebaceous units (the oil-producing glands in hair follicles) that result in increased production of the problematic sebum.
The actual cause of acne is actually not well understood, but we do know that it is often associated with a hormone imbalance that involves increased androgen production, leading to excessive sebum production.
During adolescence, both males and females have increased levels of androgens and, in perimenopause and conditions such as polycystic ovarian syndrome, this type of hormone imbalance can occur also. Acne vulgaris, or common acne, affects areas that have the largest density of sebaceous follicles, and hence occurs most commonly on the face, upper chest and back.
Some sources have suggested that in certain skin types, the stratum corneum (the outside layer of skin), grows into the pore opening, creating a condition where pores are more easily blocked than in normal skin; other sources suggest that certain individuals may naturally produce a thicker sebum that blocks the pores more readily. Although these theories have not been well demonstrated, they could explain why some people have a greater tendency to develop acne than others.
Treatments are aimed at reducing oil, decreasing bacteria counts on the skin and keeping pores open. Many of our more effective acne treatments, such as correcting underlying hormonal imbalance, reducing sebum production with vitamin A derivatives, or reducing bacteria counts through antibiotic treatments, require prescription. However, there are many non-prescription options for mild to moderate acne problems. I am one of those unfortunates who have acne-prone skin so, although I generally try to base my articles on research-based information, forgive me if I take the liberty of adding a comment or two based on personal experience.
The 3-Step Approach One trend we have seen in the acne marketplace is treatment “packages” that include a cleanser, toner and treatment cream or gel. A positive aspect of this idea is that it encourages acne sufferers to take a multiple strategy approach to treatment. Some of the more widely advertised products of this type (such as ProActiv and Acne Complex) are not available for sale in pharmacies and must be ordered by mail or Internet. However, it makes sense to simply select multiple products from the acne section with an understanding of the rationale for each, and create a customized “kit” for yourself.
Step 1: First, you want a mild cleanser, preferably soap-free, to remove excessive skin oils and some of the bacteria. The natural acidic nature of the skin is unfavourable to the growth of P. acnes and, as soaps are generally alkaline in nature, they can tend to reduce some of our natural resistance to these bacteria. Extra additives to the cleanser, such as keratolytics that mildly peel the skin, or benzoyl peroxide (discussed below), are thought to have little additional effect because of the short contact time with the skin.
While most sources recommend avoiding cleansers containing “scrubbing” particles that may increase inflammation, I have found personally that these can work well on non-inflamed acne-prone skin to prevent pores from becoming blocked by promoting exfoliation (or removal of the outer layer of dead keratin cells). Be aware, though, that many of these particles are made of plastics that can contaminate the environment – if you use one of these, choose one with natural, biodegradable particles.
Another option is to use an exfoliating sponge. Buff-Puff is one brand name, but they are available from many generic manufacturers. As exfoliation is also a common strategy for reducing the appearance of fine wrinkles, this may be an option that will interest older women with mild non-inflammatory acne. The use of an exfoliating sponge with a non-soap cleanser has been a personal favourite for 30 years; however, remember the caution against use in inflammatory acne.
Step 2: The second step, using a toner, often functions simply to remove more of the oil. Many toners have a high alcohol content, in the range of 30%, which may also kill some bacteria. Toners designed for use in acne often have 0.5 to 2% salicylic acid added, however, and this keratolytic agent, when left on the skin, can be useful to help keep pores open, preventing the trapping of oil and bacteria that is problematic in acne. Toners are designed to be applied using a cotton pad and are not rinsed from the skin afterward. Note that salicylic acid, an oil-soluble beta hydroxy acid, is often preferred in acne preparations for its ability to penetrate the oily sebum that is plugging the pores. It is sometimes referred to as a “comedolytic” action.
Some sources of information I have read in the past have suggested that alcohol alone may make an effective acne treatment, but many will complain that 70% alcohol causes burning and irritation while the lower content of alcohol in toners is generally tolerated quite easily. However, if you are a teen on a limited budget this might be a “step” to skip to reduce cost.
Conversely, an adult woman might appreciate this additional treatment from which she may benefit. As an example, one available multi-kit contains a toner with a low percentage of the alpha hydroxy acid (AHA) glycolic acid as an exfoliant to keep the pores open, while another has arnica added for its anti-inflammatory activity. A toner designed to reduce inflammation might be a welcome addition to the skincare regimen of a client with adult acne.
Step 3: The third step included in the multi-kits is a treatment gel or cream. There are numerous treatment products that we can recommend. My personal favourites, based both on theory and experience, are the benzoyl peroxide products. The maximum concentration that can be sold without prescription in Canada is 5% but in US the 10% is also out on the shelf. Most can easily tolerate 5%, but those with very sensitive skin may want to try a lower strength initially.
Be aware that benzoyl peroxide can increase sensitivity to the sun, so using it at bedtime and washing off in the morning makes sense, especially in the summer. As well, higher strengths, up to 10%, are available in Canada with a prescription. For me, a prescription for Panoxyl 10% alcohol gel was a turning point in acne control.
Benzoyl peroxide 10% would be a logical product to ask your pharmacists about, however, as they now have the ability to prescribe for acne in most jurisdictions. They would likely first ask questions about the severity of your problem, what you have already tried, and would verify that you had previously tolerated a 5% version of benzoyl peroxide.
As well as the tried and true OTC favourites, some alternative anti-acne ingredients have appeared in the literature and in various acne products. Here’s a little about how these ingredients are understood to work:
Arnica and calendula are herbal/homeopathic ingredients that have anti-inflammatory action. Calendula is also reported to have antibacterial activity.
Benzoyl peroxide is a favourite because of its dual action: it kills P. acnes bacteria plus has a keratolytic action. Don’t forget to ask about the 10% prescription if the 5% on the shelf doesn’t make a difference. Note: Be sure to use white towels and washcloths, as benzoyl peroxide will bleach coloured ones—I once ruined some of my Mom’s pretty green ones [sorry, Mom!].
Niacinamide (or nicotinamide) appears, when used as a 4 to 8% gel or cream, to have an anti-inflammatory effect and was shown to have comparable efficacy to topical clindamydin (a prescription antibiotic cream/lotion). It has also been credited with increasing synthesis of collagen and keratin, reducing skin hyperpigmentation (as can occur with acne scars), increasing skin moisture and reducing fine wrinkles. This is likely an ingredient that women with adult acne would be interested in. LaRoche-Posay’s Effaclar Duo Cream contains 8% niacinamide, or a pharmacist could compound this for you.
Resourcinol is included in acne products for its antiseptic action, presumably against P. acnes, and is often combined with the keratolytic, salicylic acid.
Sulfur, commonly found in acne products, is effective as a micro-exfoliant and a mild antiseptic and is probably the oldest known acne remedy, having been cited in ancient Greek, Roman and Chinese texts for this use. It is also helpful in promoting collagen synthesis, and is an active ingredient in lotions, creams, gels, washes and shampoos. It has also been used for seborrheic dermatitis, rosacea, eczema, psoriasis, and, in much higher concentrations, for scabies and lice.
Tea tree oil (5%) has been cited as being comparable in effect to benzoyl peroxide but without excessive drying, so might be a good option for adult acne. It kills P. acnes and has been shown to have anti-inflammatory action. It would also present a good option for those allergic or sensitive to benzoyl peroxide, or for those who are keen on a more natural option.
Zinc supplements, taken by mouth, have been shown to be helpful in inflammatory acne, although less so than oral tetracyclines (prescription antibiotic). Zinc tablets would also present an option for those who wish to avoid long-term antibiotics.
Camouflage techniques Acne can be a distressing condition, particularly when it occurs at adolescence, a difficult time for many. It is natural for many teenagers, especially girls, to want to “cover up” their acne, and some advice from a pharmacist or trained cosmetician may help them to successfully do this without making their acne worse.
First, be sure to realize that bacteria, including the P. acnes that are involved in the acne process, can grow in your makeup products. Wash your hands before using, avoid dipping into the product with your fingers, and replace the products regularly. Use oil-free cosmetics to avoid adding additional oil to skin that is most likely already producing too much. Sheer or translucent makeup is recommended for commodonal acne, and fuller, opaque types for lesions or scars. You can also mix translucent powder with your makeup or dust it on afterward for better coverage. Multiple thin layers can be applied for additional coverage with drying time between.
Skin camouflage, such as Hyperflage, Dermablend, and CoverMark Face Magic, may be “just what the pharmacist ordered” for a teenager with acne heading to a special event. Proper application is important for best results and, generally, these products include instructions for use that should be read carefully to achieve a natural look. General recommendations are to cleanse the skin first, apply the camouflage makeup sparingly, blend the edges carefully, let dry, then apply foundation with a dry wedge sponge, if desired.
Previously published in Drugstore Canada
